Calf Augmentation with AutologousTissue Injection

Sir: We read with great interest the article by Dr. Erol et al. on calf augmentation1 and the reply from doctor Niechajev.2 We compliment both authors for their work. We totally agree with the authors that autologous fat grafting is a reproducible, safe technique, with good long-lasting results. In our institution, this technique is the first choice for treatment of lower limb atrophies.3 Regarding the study we have conducted, some additional points seem to be interesting for this discussion. First, from a didactic point of view, lower extremity atrophies should be classified into two categories: circumferential atrophies and localized atrophies.3 Circumferential atrophies can be unilateral or bilateral and have various causes: congenital, infectious (e.g., poliomyelitis), iatrogenic, traumatic (e.g., traumatic degloving), and sciatic or tibial nerve injury. The localized atrophies concern only a limited zone of the lower extremity. Causes are usually traumatic or iatrogenic, such as intramuscular injections or postliposuction irregularities. The point of this classification was to describe an algorithm of treatment3: For localized atrophies, different options as follows could be considered: excision and primary closure for small atrophies, tissue expander and local flap for medium size atrophies, and autologous fat grafting combined with a peripheral liposuction for wider atrophies. For circumferential atrophies, the principal limiting factor for the treatment of the circumferential lower extremity atrophies is the laxity of skin and the adherence of the skin to the deep plane.4 Depending on this laxity, multisession fat grafting is performed,5 and if the result is not sufficient, a silicone implant is used to create more volume. Thus, fat grafting is used to prepare the recipient site for silicone implant calf augmentation.6 Fat grafting can also be performed after silicone implant augmentation to hide visible borders of the implant. Second, patient self-assessed evaluation revealed a 75 percent satisfaction rate for the treatment of circumferential atrophies and an 85 percent satisfaction rate for localized atrophies with an average follow-up period of 2 years (range, 1 to 3.6 years).3 However, subjective assessment is not enough, and a quantitative assessment by measuring the perimeter of the lower extremity at three different levels is a more consistent and relevant means of analyzing the increase of the volume and the perimeter. Levels measured for each patient before and after surgery were the anterior tibial tuberosity, the middle calf, and the supramalleolar level (Fig. 1). In our study, circumferential atrophies had an average increase of the perimeter of 1.9 cm (range, 1 to 6 cm) after each injection. Quantitative assessment by measuring the perimeter is an efficient, easy, and reproducible method. It allows us to follow the stability of the outcome.Fig. 1.: Preoperative measurements of the different perimeters of the limb (anterior view).Third, if the lower extremity is considered as a cylinder, with height (h) and radius (r), the comparison of its volume (hπr2) with the opposite site (which serves as the reference) shows an important difference of volume (Fig. 2).Fig. 2.: Optimization of fat tissue injection with circumferential atrophies. The asterisk (*) indicates the focused zone of volume injection primarily in both lateral and medial sides of the leg. w, width; h, height; ANT, anterior; POST, posterior.Regarding this important quantity of fat tissue needed to increase the volume, one can easily understand that reconstruction of the volume of the entire leg is not feasible, especially because of the lack of a donor site. For this reason, we focused the increase of volume primarily on both lateral and medial sides of the leg before treating the entire circumference. This allows for an improvement on the anteroposterior view, and if fat grafting alone is not sufficient, we can prepare the subcutaneous pocket for a silicone implant. In conclusion, autologous fat grafting can be the only treatment for calf augmentation with localized or circumferential atrophies and can also be associated with other procedures such as peripheral liposuction, contralateral liposuction, and silicone implant–based augmentation. Michael Veber, Jr., M.D. Ali Mojallal, M.D.